Provider Demographics
NPI:1740473503
Name:FLEMING, MARK (AOD COUNSELOR)
Entity type:Individual
Prefix:MR
First Name:MARK
Middle Name:
Last Name:FLEMING
Suffix:
Gender:M
Credentials:AOD COUNSELOR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:330 MCHENRY AVE
Mailing Address - Street 2:
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95354-0561
Mailing Address - Country:US
Mailing Address - Phone:209-577-3595
Mailing Address - Fax:209-577-4150
Practice Address - Street 1:330 MCHENRY AVE
Practice Address - Street 2:
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95354-0561
Practice Address - Country:US
Practice Address - Phone:209-577-3595
Practice Address - Fax:209-577-4150
Is Sole Proprietor?:No
Enumeration Date:2007-08-23
Last Update Date:2007-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1740320019101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1740320019Medicaid